A managed care plan, as defined in rule 5160-26-01 of the Administrative Code, shall inform an affected individual and any authorized representative of the individual on file with the managed care plan by providing notice of its denial, reduction, suspension, or termination of a medical service, as described in this rule.
(A) Timing of notice
(1) The managed care plan shall mail or personally deliver notice of denial at the time the decision to deny the service is made.
(2) The managed care plan shall mail or personally deliver to the enrollee a notice of denial of payment whenever the provider bills an enrollee for a service due to denial of payment by the managed care plan.
If an enrollee contacts the managed care plan and indicates that he or she has received a bill, and not received proper notice, as required by this rule, and the managed care plan's response is to uphold the denial of payment, the managed care plan shall mail or personally deliver notice at that time.
(3) The managed care plan shall mail or personally deliver notice of reduction, suspension, or termination no later than fifteen calendar days prior to the effective date of the proposed action.
(4) If the decision to deny, reduce, suspend, or terminate service or affirm billing of an enrollee due to the managed care plan's denial of payment for the service, is the result of a managed care plan grievance, notice of that decision shall be mailed or personally delivered at the time the grievance is decided.
(B) "Reduction, suspension or termination" of a service means that the service is being reduced from the level authorized, suspended or terminated, prior to the expiration of the prescribed period. If, upon the expiration of a period of authorized service, the enrollee requests further services, denial of that request shall be considered a denial, rather than a reduction, suspension, or termination, of service and continuation of benefits as described in rule 5101:6-4-01 of the Administrative Code will not apply.
(C) The notice shall contain a clear and understandable statement of the action and the reasons for it, cite the applicable regulations, explain the individual's right to and the method of obtaining a state hearing, explain the circumstances under which a timely hearing request will result in continued services, and contain a telephone number to call about free legal services.
(D) For denial of a medical service, the JFS 04043 "Notice of Denial of Medical Services by Your Managed Care Plan," (rev. 7/2009), shall be used. For reduction, suspension, or termination of a medical service, the JFS 04066 "Notice of Reduction, Suspension, or Termination of Medical Services by Your Managed Care Plan," (7/2009), shall be used. For denial of payment, the JFS 04046 "Notice of Denial of Payment for Medical Services by Your Managed Care Plan," (rev. 7/2009), shall be used.
R.C. 119.032 review dates: 11/18/2013 and 02/01/2019
Promulgated Under: 119.03
Statutory Authority: 5101.35
Rule Amplifies: 5101.35 , 5160.011
Prior Effective Dates: 11/1/89 (Emer), 1/29/90, 10/1/90, 6/1/93, 6/1/97, 10/1/97 (Emer), 12/30/97, 10/1/02, 9/1/08, 7/1/09, 8/1/10